1 Introduction

Fragility fracture patients (FFPs) are medically complex and typically present with more than a single medical problem. While some of these problems are apparent, others may remain unrecognized and lead to complications and adverse outcomes. Because of this typical complexity, systematic efforts are necessary to routinely obtain detailed patient-specific clinical information and to set patient-specific goals. This approach requires a coordinated team of health professionals, each of whom is focused on specific aspects of care ( Fig 2.6-1 ).

A systematic approach helps to manage this information and to detect underlying cognitive, functional, medical, and social problems that are likely to impact outcomes and effect prognosis. For the team to work effectively, it is essential to clearly define the orthogeriatric team and the roles of each member. This chapter is written based on the academic and clinical experience of a mature orthogeriatric team using the principles of orthogeriatric comanagement (see chapters 2.1 Models of orthogeriatric care and 2.4 Elements of an orthogeriatric comanaged program) [1].

2 The comorbidity construct

The comorbidity construct ( Fig 2.6-2 ) is a useful tool to get a better overview of the complexity that needs to be addressed for most FFPs [2]. This approach should help illustrate the necessary components and goals of the orthogeriatric team.

Usually, the index disease (ie, fragility fracture) leads to hospital admission. In order to prioritize the treatment goals, it is worthwhile to identify and define additional important conditions:

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  Comorbidities are medical conditions that are strongly interrelated with the index disease and the outcomes of interest. When treating the index disease, you have to include the comorbidities in the treatment plan for an optimal outcome.

  
  
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  Multimorbidity refers to the total burden of other diseases in a patient. These may play a general role in outcomes, but may not be modifiable, or need to be specifically addressed during the hospitalization.

  
  
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  Interestingly, the impact of the chronological age is not as significant. The biological age of patients and the estimated life expectancy are more relevant for the outcome.

  
  
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  Fragility fractures are mainly a result of a low-energy trauma, eg, a fall from standing height. In older patients, intrinsic factors are a major contributor in terms of falls. Besides comorbidities, health-related individual attributes must be taken into consideration. Health-related attributes are existing or developing functional disabilities and geriatric syndromes (eg, frailty, gait instability, cognitive impairment, urinary incontinence). They all contribute to the overall morbidity burden.

  
  
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  Finally, the complexity of patients’ conditions result from their nonhealth-related individual attributes (eg, personality, social supports, and financial supports).

By using this systematic framework in the rather simple example described in Fig 2.6-1 , the team is more likely to identify the relevant medical and social problems and better address those conditions that are likely to impact recovery from fracture repair and attainment of the highest level of function ( Fig 2.6-3 ). When applying the comorbidity construct to this specific example, it becomes clear that:

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  The index disease for hospital admission is the hip fracture.

  
  
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  A contributing comorbidity is osteoporosis. There is a strong relationship between the fracture and osteoporosis. When treating FFPs, you should initiate osteoporosis care. Otherwise, you will miss an opportunity; probably the most important in terms of secondary fracture prevention, and your case management will be at risk to fail.

  
  
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  Other potentially important comorbidities are heart failure, hypertension, and depression. Their impact on short-term recovery is not entirely clear and may be influenced by the severity of each disease and other individual factors. The team must evaluate which medical conditions might have an impact on the outcome of the patient and need to be included in the team′s treatment plans.

  
  
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  Gender aspects should also be considered. Usually, male patients have worse outcomes than female patients. Social environments are not comparable.

  
  
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  The correlation of increased age and mortality is mainly the result of the higher prevalence of disease and functional disabilities with increasing age. For highly functional and healthy adults, the correlation between age and mortality is not strong [3].

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  In terms of goal setting, life expectancy should be estimated. Functional and robust older adults may still have a remarkably long life expectancy. In the example case, the life expectancy was limited, but not so much as to preclude fracture repair and an attempt at rehabilitation (see chapter 1.5 Prognosis and goals of care).

  
  
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  Different functional disabilities such as immobility, malnutrition, cognitive impairment, pain, polypharmacy, and dysphagia may be present. These health-related individual attributes can have more impact on the outcome than the index diagnosis and should be specifically and systematically addressed by the team.

  
  
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  Finally, morbidity burden not only reflects the diagnosis but also the functional disabilities of a patient.

  
  
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  Based on a holistic approach, the orthogeriatric team also has to assess for nonhealth-related individual attributes including the social environment. The social network is not only extremely important for discharge planning but also for reduction of readmissions and secondary fracture prevention.

3 Goal setting

After having collected all information by using the comorbidity construct, the process of goal setting starts. This process should be based on the following principles:

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  Ensure the goal you set is specific, clear, and attainable.

  
  
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  The goal should be measurable, ie, if you cannot measure it, you cannot manage it.

  
  
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  A goal needs to be attractive and acceptable to the patient, family, and team.

  
  
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  The timeline should be considered by setting short-term as well as long-term goals. Usually, the long-term goal is the expected outcome in several weeks, ie, “to live independently” or “to walk without using a walking aid”. In order to achieve the long-term goal, it is necessary to meet different short-term goals for each problem, like walking with a roller after the first week or removing the urine catheter within 2 or 3 days after surgery. The goals may be changed due to medical complications or if patients were to become unwilling or unable to continue or if they progress more slowly or quickly than expected.

Goal setting should be integrated into the regular team meetings.